Provider Demographics
NPI:1346322559
Name:RISVOLD, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RISVOLD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100216
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99510-0216
Mailing Address - Country:US
Mailing Address - Phone:907-529-1898
Mailing Address - Fax:
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-3941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37737207L00000X
AK5124207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK5124Medicaid
AK5124Medicaid